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2009 Korean Pharmacopuncture Institute

J Acupunct Meridian Stud2009;2(4):309320

EDUCATION

1. Introduction

Acupuncture as a medical science has constantly

evolved, particularly since 1950s, when the science

of acupuncture became widely developed, both in

theory and practice [1]. There are two generalviewpoints regarding how acupuncture functions

[2]. One is the classic Qi model, which involves the

meridian and acupoint system based on the theo-

ries of Yin-Yang and a Five Element system, and

the other is related to the Western neurophysio-

logical model, which is based on neuroendocrine,

immunological, and other physiological processes.

Recently, the functions of acupuncture were studied

on the basis of findings from radiological instru-

ments, such as functional magnetic resonance im-

aging and positron emission tomography [3]. Cho

et al were the first to identify relationships be-

tween particular acupoints and visual-cortex

activation using functional magnetic resonance

imaging [4,5]. Ma et al proposed the integrative

neuromuscular acupoint system for pain manage-

ment, producing a standardization of the treat-

ment procedure [6].

In the classical Qi model, most illnesses and dis-

turbances are known to be rooted in interruptions

AbstractThis study is a review of the theoretical basis of Sa-Ahm Five Element acupunc-

ture devised about 360 years ago. A total of 21 books and papers ranging from the

ancient Huang Di Nei Jing to modern biomedical acupuncture for pain manage-

ment were researched in relation to the Five Shu points. Gao-Wu, in the Chinese

Ming Dynasty, used the Five Shu points for the first time based on the creation cycle

as the tonification and sedation treatment, termed the tonification and sedation

treatment of self meridian. Since then, and for no particular reason, this method

has been rarely used until Sa-Ahms new doctrine, which includes the concept of

the destruction cycle, was asserted. Sa-Ahm Five Element acupuncture is a method

in which the Five Shu points are used from the viewpoints of the simultaneous toni-fication and sedation methods that are based on the promotion and control cycles.

Although it is currently the most utilized method in accordance with the practi-

tioners points, this method is in need of designated guidelines by which Sa-Ahm

acupuncture can be practiced effectively.

Received: Aug 10, 2009

Accepted: Sep 4, 2009

KEY WORDS:

clinical guidelines;

Five Shu points;

neurophysiological

mechanisms of

acupuncture;

Sa-Ahm Five Elementacupuncture;

tonification and sedation

treatment

A Study of the Sa-Ahm Five ElementAcupuncture Theory

Chang-Beohm Ahn1*, Kyung-Jun Jang1, Hyun-Min Yoon1, Cheol-Hong Kim1,Young-Kwang Min1, Chun-Ho Song2, Jang-Cheon Lee3

1Department of Acupuncture & Moxibustion, College of Oriental Medicine, Dongeui University, Busan, Korea2Department of Meridian & Acupoint, College of Oriental Medicine, Dongeui University, Busan, Korea3Division of Pharmacology & Prescriptionology, School of Oriental Medicine, Pusan National University,

Busan, Korea

*Corresponding author. Department of Acupuncture & Moxibustion, College of Oriental Medicine, Dongeui University,

614-052 Busan, Korea.

E-mail: cbahn@deu.ac.kr

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310 C.B. Ahn et al

or imbalances within or over a network of meridi-

ans; interruptions are stagnation and irregularity,

while imbalances are deficiency and excess [7].

The acupoints in and around the local areas, special

points such as connecting, cleft, and alarm points,

could be used for interruptions in correlation to an

acupoints efficacy, but the Five Shu points, lo-

cated below the elbow and knee joints, could be

used corresponding to the Five Phases for imbal-

ances in correlation to tonification and sedation [8].

The 50th issue ofNan-Ching explains the pathol-

ogy of the Five Evils [9,10] and the 69th issue of

Nan-Ching describes the treatment for these evils.

Gao-Wu, during the Ming Dynasty (1519 AD), was the

first and foremost medical acupuncturist to tonify

deficiency and sedate excess on the basis of either

depletion or repletion of the promotion cycle,

which is explained in The Four Needle method

by Ross [7,11].

The Korean monk, Sa-Ahm [12], about 360 years

ago, proposed Five Element acupuncture that si-multaneously uses the Five Shu points of the pro-

motion and control cycles, called the Four Needle

technique by Hicks et al [13] and the Eight

Needle method by Ross [7]. This method consists

of, in a broad sense, the method of tonification-

sedation between deficiency and excess as well

as the method of tonification-sedation between

coldness and heat.

In this report, the theory of Sa-Ahm acupunc-

ture is briefly reviewed to improve the understand-

ing of the theorys details, based on Ahns treatise

[14] as well as from review of the content of otherforeign scholars treatises [7,13].

2. Basic Theory

2.1. The root of diseases

Most illness and disturbances are rooted in interrup-

tions or imbalances in a network of meridians. In-

terruptions comprise stagnation and irregularities,

and imbalances are deficiency and excess [7].

2.2. The effect of acupuncture points andmajor rules of point selection

In acupuncture, point selection for treatment,

major empirical principles, and rules based on the

traditional knowledge of Oriental medicine are

employed. These acupuncture tools have been

extended over the last 30 years through the find-

ings of modern scientific research.

For interruptions, acupoints may be selected

based on local and special effects in correlation to

the efficacy of an acupoint while, for imbalances,

the Five Shu points may be selected either by defi-

ciency or excess in correlation with tonification

and sedation.

2.2.1. Efficacy of acupoints

(a) Every acupuncture point has a local effect on

the surrounding area. ST8 (Touwei), for exam-

ple, is a local point selected for the treatment

of temporal headache [15].

(b) Painful, indurated (e.g. myogelosis), and tender

points with no relation to a channel are also used

as local acupuncture points (also called locus

dolendi points or, in Oriental terms, Ah-Shi

points).

(c) Every acupuncture point has an effect on distur-

bances of the corresponding channel and the

coupled channel as well as on the illness of the

corresponding organ, the allocated tissues and

sensory organs.

(d) Acupuncture points have an effect on the re-lated channel axis, for example, ST38 (Tiaokou)

along the Yang-Ming (stomach-large intestine)

on the shoulder.

(e) Points located distal to the elbow and knee are

called the distal points and have an influence

on proximal areas, such as head, neck, and face,

and on the corresponding channel.

(f) According to the scientific findings, some acu-

puncture points have been designated as having

analgesic, sedative, immune-enhancing, tonify-

ing or homeostatic effects.

(g) Some acupuncture points with specific effectsare used for symptomatic treatments, such as

hiccupping, nausea, sweating, sneezing, insom-

nia, fever, impotence, constipation, diarrhea,

and speech disturbance.

(h) Special points are used (e.g. Luo and Yuan

points, He points, Luo connecting points, Xi-

cleft points, eight influential points, Mu or

alarm points, back Shu or back transporting

points, and eight confluent points).

2.2.2. Tonification and efficacy of sedation

(a) The Five Shu points distal to the elbow and kneecorrespond to the Five Phases and have been

used in clinical treatments depending on each

points different effects and indications (Table 1).

(b) The Five Shu points include a tonification point

and a sedation point. The latter, which corre-

sponds to the mother element according to

the law of the Five Phases, tonifies the energy

of the corresponding channel and organ. Thus,

the tonification points are needled in organ

deficiency conditions and the channel with

stimulation by the tonifying method.

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Sa-Ahm Five Element acupuncture theory 311

(c) The sedative point of the Five Shu points cor-

responds to the son element according to the

law of Five Phases. The Qi of channels and or-

gans can be sedated by stimulation of this point.

Thus, this point is needled in excess conditions

with stimulation by the sedating method.

2.3. Characteristics of the Five Shu points

Giovanni [16]: The sections of channel between

fingers/toes and elbows/knees are more superfi-

cial than the rest, which is one of the reasons for

the importance of the points lying along its path.

The energetic action of the points along a section

of such a channel is much more dynamic than other

points, which explains their frequent use in clini-

cal practice. Another reason for the dynamism of

these points is that, at the tips of fingers and toes,

the energy changes polarity from Yin to Yang or

vice versa and, due to this polarity change, the Qi

of the channel is more unstable and thus more eas-ily influenced. The progression of the Five Element

points along the channel is probably in relation to

this change of polarity, as the second point belongs

to the Fire in the Yin channels and the Water in the

Yang channels. Five points situated along this chan-

nel section are particularly important and are

called the Five Transporting points; they also coin-

cide with what are called the Elements points.

However, the dynamic of these points is irrespec-

tive of their Five Elements character.

Yun-Tao-Ma [6]: An interesting neurologic fact

is that the limbs below the elbows and knees oc-cupy large regions in the brain sensory gyrus. Thus,

the acupoints below the elbows and knees also

occupy a large region in the cortical representa-

tion of the brains postcentral sensory gyrus. This

correlation may explain the reason why the acu-

points below the elbows and knees contain more

sensory receptors and needling stimulation of

these points can induce a greater reaction and ac-

tivity in the brain. This principle clearly supports

the concept of using certain acupoints below the

elbows and knees (the so-called Five Shu points

in the classic meridian system) as diagnosis and

treatment points during acupuncture treatment.

3. The Difficult Issues in Nan-Ching

3.1. The 50th difficult issue

Among the illnesses are the depletion, repletion,

destroyer, weakness, and regular evils. How are

they distinguished?

(a) Those (illnesses) coming from behind represent

a depletion evil.

(b) Those coming from ahead represent a repletionevil.

(c) Those coming from what cannot be overcome

represent a destroyer evil.

(d) Those coming from what can be overcome rep-

resent a weakness evil.

(e) If the respective depot is afflicted from within

itself, it represents a regular evil.

3.2. The 69th difficult issue

In case of depletion, it should be filled, while in

case of repletion, it should be drained. When nei-ther repletion nor depletion is present, the illness

should be removed from the conduits. What does

that mean? In the case of depletion, fill the respec-

tive (conduits) mother. In case of repletion, drain

Table 1 The Five Shu points of the 12 meridians

Yin median Wood (Well) Fire (Spring) Earth (Stream) Metal (River) Water (Sea)

Lung (Metal) LU11 LU10 LU9 LU8 LU5

Heart (Fire) HT9 HT8 HT7 HT4 HT3

Pericardium (Fire) PC9 PC8 PC7 PC5 PC3Spleen (Earth) SP1 SP2 SP3 SP5 SP9

Kidney (Water) KI1 KI2 KI3 KI7 KI10

Liver (Wood) LR1 LR2 LR3 LR4 LR8

Yang meridians Metal (Well) Water (Spring) Wood (Stream) Fire (River) Earth (Sea)

Large intestine (Metal) LI1 LI2 LI3 LI5 LI11

Small intestine (Fire) SI1 SI2 SI3 SI5 SI8

Triple energizer (Fire) TE1 TE2 TE3 TE6 TE10

Stomach (Earth) ST45 ST44 ST43 ST41 ST36

Bladder (Water) BL67 BL66 BL65 BL60 BL54

Gallbladder (Wood) GB44 GB43 GB41 GB38 GB34

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the respective (conduits) child. One must fill first

and then drain afterward.

3.3. The controller (governor) cycle

This characteristic of Sa-Ahms acupuncture is the

addition of the control (grandmother-grandchild)

cycle to the promotion cycle (mother and son ele-

ments). This method, surprisingly, includes a new

concept of the governor meridian in the applica-

tion of the law of the Five Elements based on the

inter-destructive cycle (Figure 1; Table 2).

3.4. Applied principle for treatment

Wang Sheng Xiu Qiu Si is another of Wu Xings con-

cepts [17]; Wang Sheng Xiu is a family and in a

promotion cycle of the Five Phases, while Qiu Si is

an enemy and in a control cycle of the Five Phases.

In promoting the cycle of the Five Phases, a rein-

forcing method can be done while in control cycle

of the Five Phases, requiring a reducing method.

It is meaningful that each element promotes like a

family in the promoting cycle while each element

reduces like an enemy (Table 3).

3.5. Tonification and sedation by Gao-Wu

3.5.1. The basic theory

In deficiency, to determine which site is the tonifi-

cation point for a meridian, one selects the Mother

Element on the meridian in question. In the case

of the Lung meridian, for example, the Mother

Element of the Lung is Earth (Earth is the Mother

of Metal), and thus the tonification point of the

Lung meridian would therefore be the Earth point

on the Lung meridian, namely Lung 9 [11].

In excesses, to determine which is the sedationpoint for a meridian, one selects the Child Element

on the meridian in question. In the case of the

Lung meridian, the Child Element of the Lung is

Water (Water is the Child of Metal), and thus the

sedation point of the Lung meridian would be the

Water point on the Lung meridian, namely Lung 5.

The same principle holds true for the other eleven

regular meridians [11].

3.5.2. The Four Needle method: combiningthe Within-and-Between Elements

treatments

This consists of the Within-Reinforce-Tonification

point and the Within-Reduce-Sedation point, which

are tonification and sedation of Gao-Wu, as well as

the Between-Reinforce-Element point and the

Between-Reduce-Element point [7], which are

Table 2 The 12 meridians according to the mother-son-governor law

Organs Mother Son Governor

3 Yang meridians large intestine (Metal) stomach (Earth) bladder (Water) small intestine (Fire)

(hand) small intestine (Fire) gallbladder (Wood) stomach (Earth) bladder (Water)triple energizer (Fire) gallbladder (Wood) stomach (Earth) bladder (Water)

3 Yang meridians stomach (Earth) small intestine (Fire) large intestine (Metal) gallbladder (Wood)

(foot) bladder (Water) lung (Metal) gall (Wood) stomach (Earth)

gallbladder (Wood) bladder (Water) heart (Fire) lung (Metal)

3 Yin meridians lung (Metal) spleen (Earth) kidney (Water) heart (Fire)

(hand) heart (Fire) liver (Wood) spleen (Earth) kidney (Water)

pericardium (Fire) gallbladder (Wood) stomach (Earth) bladder (Water)

3 Yin meridians spleen (Earth) heart (Fire) lung (Metal) liver (Wood)

(foot) kidney (Water) lung (Metal) liver (Wood) spleen (Earth)

liver (Wood) kidney (Water) heart (Fire) lung (Metal)

Figure 1 The Five Phases of the creation and governorcycles in relation to the 12 meridians.

Fire

PC HT

SP ST

LU

LI

KI

BL

LRGB

Wood Earth

Water Metal

TE SI

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Sa-Ahm Five Element acupuncture theory 313

tonification and sedation among other meridians,

and are used in Sa-Ahms acupuncture (Table 4).

3.6. Tonification and sedation by Sa-Ahm

This makes use of the tonification and sedation

points along the promotion cycle as well as points

along the control cycle in cases of deficiency and

excess; and along the fire and water meridians incases of heat and coldness.

3.6.1. Tonification and sedation fordeficiency and excess

The basic rules, based on the writings ofNan-Ching

[9,10], are those of the creation (mother-son) and

governor (destruction) relationships. In the case of

any meridians insufficiency (weakness), the points

of its mother and its own meridians should be toni-

fied and the points of its governor and its own me-

ridians should be sedated. In the case of anymeridians excessiveness (fullness), the points of

its governor and its own meridians should be toni-

fied and the points of its son and its own meridians

should be sedated [18] (Figure 2).

3.6.1.1. In deficienciesNeedle 1: Tonify the deficient meridian at its

mother (tonification) point. With a Lung defi-

ciency, tonify the Earth point of the Lung,

Lung 6.

Needle 2: Tonify the master point on the Mother

Element. The Mother of Metal is Earth, hence, the

Mother of Lung is Spleen and the master (Earth)point of the Spleen (Earth), namely Spleen 3,

should be tonified.

Needle 3: Sedate the Controller Element on the

affected meridian. The Controller of Metal is Fire,

so the Fire point on the affected meridian, the

Lung or Lung 10, should be selected.

Needle 4: Sedate the master point on the

Controller Element. The Controller Element is Fire;

hence the Controller of lung is Heart. The master

(Fire) point on the Heart (Fire), namely Heart 8,

should be sedated.

To summarize this principle for deficiency con-

ditions [19]:

Tonify the first 2 needles,

Tonify the Mother Element point on the affected

meridian,

Tonify the master point on the Mother Element

itself;

Sedate the second 2 needles,

Sedate the Controller Element point on the af-

fected meridian,

Sedate the master point on the Controller

Element.

For example, if the stomach is believed to be

underactive: (a) Fire tonification, stomach meridian-

Fire point ST41, small intestine meridian-Fire point

SI5; (b) Wood sedation, stomach meridian-Wood

point ST43, gallbladder meridian-Wood point GB41

(Table 5). The other meridians follow the same

rule, as described above.

3.6.1.2. In excessesNeedle 1: Sedate the Child Element point on the

affected meridian. For Spleen excess, the Metal

Table 3 The relationship between the Five Evils and Five Phases

Relationship

Mother

Self

ChildEnemy whom Enemy who

I control controls me

Five Evil depletion regular repletion weakness destroy

Wang Sheng Xiu Wang Sheng Qiu Si

Principle for Deficiency; Self tonify or Excess; Deficiency; to Deficiency;

treatment to tonify self sedate to sedate sedate enemy to sedate,

the mother the child excess; to tonify enemy

Table 4 The Four Needle method: combining theWithin and Between Elements treatments

Deficiency Excess

within between within betweenChannel

reinforce reinforce reduce reduce

tonification element sedation element

point point point point

KI KI7 LU8 KI1 LR1

BL BL67 LI1 BL65 GB41

HT HT9 LR1 HT7 SP3

SI SI3 GB41 SI8 ST36

PC PC9 LR1 PC7 SP3

TE TE3 GB41 TE10 ST36

LR LR8 KI10 LR2 HT8

GB GB43 BL66 GB38 SI5

SP SP2 HT8 SP5 LU8

ST ST41 SI5 ST45 LI1

LU LU9 SP3 LU5 KI10

LI LI11 ST36 LI2 BL66

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(Child) point of the Spleen, sedation point Spleen

5, should be sedated.

Needle 2: Sedate the master on the Child merid-

ian. The Child of Spleen is Lung. The master (Metal)

point of the Lung, Lung 8, should be sedated.

Needle 3: Tonify the Controller Element on the

affected meridian. The Controller of Earth is Wood

and thus the Wood point on the Spleen (Earth) me-

ridian, Spleen 1, should be tonified.

Needle 4: Tonify the master point on the

Controller. The Controller is Liver (Wood) and thusthe master (Wood) point on the Liver, namely Liver

1, should be tonified.

To summarize this principle for excess condi-

tions [19]:

Sedate the first 2 needles,

Sedate the Child Element (sedation) point on

the affected meridian,

Sedate the master point on the Child meridian;

Tonify the second 2 needles,

Tonify the Controller Element on the affected

meridian,

Tonify the master point on the Controller

meridian.

For example, if the stomach is believed to be

overactive: (a) The stomach meridian belongs to the

element of Earth and should be sedated by sedation

at the Metal point, which is ST45, of its own merid-

ian in accordance with the mother-son (creative

cycle of the Five Elements) law. Metal is the son of

Earth. Also, the Metal point of the large intestine,

LI1, the son meridian of the stomach meridian,

should be sedated. (b) The gallbladder meridian isopposed to the stomach meridian by the destructive

cycle of the law of the Five Elements (the governor

meridian). This meridian should be tonified at its

Wood point, GB41, to destroy the overactive ele-

ment of Earth. Also the stomach meridian should be

tonified at its Wood point, ST43, to destroy the ele-

ment of Earth within the self meridian (Table 5). The

other meridians follow the same rule described

above.

Ross [7] calls acupoint selection of tonification

and sedation among its own meridians Within

Table 5 Sa-Ahms points of tonification for deficiency and sedation for excess

Deficiency (tonification) Excess (sedation)Meridians

Tonify Sedate Tonify Sedate

Lung SP3 LU9 HT8 LU10 HT8 LU10 KI10 LU5

Large intestine ST36 LI11 SI5 LI5 SI5 LI5 BL66 LI2

Stomach SI5 ST41 GB41 ST43 GB41 ST43 LI1 ST45

Spleen HT8 SP2 LR1 SP1 LR1 SP1 LU8 SP5

Heart LR1 HT9 KI19 HT3 KI19 HT3 SP3 HT7

Small intestine GB41 SI3 BL66 SI2 BL66 SI2 ST36 SI8

Bladder LI1 BL67 ST36 BL54 ST36 BL54 GB41 BL65

Kidney LU8 KI7 SP3 KI3 SP3 KI3 LR1 KI1

Pericardium LR1 PC9 KI10 PC3 KI10 PC3 SP3 PC7

Triple energizer GB41 TE3 BL66 TE2 BL66 TE2 ST36 TE10

Gall BL66 GB43 LI1 GB44 LI1 GB44 SI5 GB38

Liver KI10 LR8 LU8 LR4 LU8 LR4 HT8 LR2

Treatment

Principles

Treatment points

Deficiency Excess

To tonify therespective mother;

to sedate thedestroyer

To tonify themother point ofmother channeland self-channel

To sedate thedestroyer point ofdestroyer channeland self-channel

To tonify thedestroyer;

to sedate therespective son

To sedate sonpoint of son channel

and self-channel

To tonify thedestroyer point ofdestroyer channeland self-channel

Figure 2 Principle and acupuncture selection for deficiency and excess treatment.

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Sa-Ahm Five Element acupuncture theory 315

Element treatments and acupoint selection oftonification and sedation among other meridians

Between Element treatments. This selection, the

Four Needle method, is based on the theory of pro-

motion cycle of the Five Elements. He also explains

the Eight Needle method which selects another

acupoint based on the theory of the inhibition

cycle of the Five Elements, in addition to the Four

Needle method. He did not explain the originality

of its treatments, but the selection is the same

as the Sa-Ahm Five Element acupuncture (Tables 6

and 7).

3.6.2. Tonification for cold symptoms andsedation for fire symptoms

Some kinds of diseases are caused by the imbalance

between fire and coldness in the body and the cor-

responding treatments consist of using the Water

and Fire points along the self meridian, the Water

meridian, and the Fire meridian. For a fire symptom,

the Water points of the master and Water meridians

are selected to tonify the Water, as well as the Fire

points of the master and Fire meridians selected to

sedate the Fire. For a cold symptom, the Fire points

Table 6 The Eight Needle method in deficiency over control

Deficiency (over control)

Reinforce Element point of Element point of

Channel tonification point motherReduce control point

grandmother

of grandchild (betweenof grandchild

(between

(within element) elements)(within element)

elements)

KI KI7 LU8 KI3 SP3

BL BL67 LI1 BL40 ST36

HT HT9 LR1 HT3 KI10

SI SI3 GB41 SI2 BL66

PC PC9 LR1 PC3 KI10

TE TE3 GB41 TE2 BL66

LR LR8 KI10 LR4 LU8

GB GB43 BL66 GB44 LI1

SP SP2 HT8 SP1 LR1

ST ST41 SI5 ST43 GB41

LU LU9 SP3 LU10 HT8

LI LI11 ST36 LI5 SI5

Table 7 The Eight Needle method in deficiency under control

Deficiency (under control)

ReduceElement point Reinforce control Element point ofChannel sedation point

of child point of grandchild grandmotherof grandchild

(between elements) (within element) (between elements)(within element)

KI KI1 LR1 KI3 SP3

BL BL65 GB41 BL40 ST36

HT HT7 SP3 HT3 KI10SI SI8 ST36 SI2 BL66

PC PC7 SP3 PC3 KI10

TE TE10 ST36 TE2 BL66

LR LR2 HT8 LR4 LU8

GB GB38 SI5 GB44 LI1

SP SP5 LU8 SP1 LR1

ST ST45 L11 ST43 GB41

LU LU5 KI10 LU10 HT8

LI LI2 BL66 LI5 SI5

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316 C.B. Ahn et al

of the master and Fire meridians are selected to

tonify the Fire, as well as the Water points of the

master and Water meridians selected to sedate

coldness (Figure 3).

3.6.2.1. Cold symptomsIn the case of cold symptoms in the lungs, the cold

symptom can be balanced by both the tonification

of heat and sedation of coldness. Accordingly, the

Fire points, Yuji (LU10) of the self meridian and

Shaofu (HT8) of the Fire (heart) meridian, should

be tonified to warm coldness. Conversely, the

Water points, Chize (LU5) of the self meridian and

Yingu (KI10) of the Water (kidney) meridian, should

be repressed (Table 8). The other meridians follow

the same rules described above.

3.6.2.2. Fire symptomsIn the case of heat symptoms in the lungs, the Fire

symptom can be controlled by Water, and the

Water points, Chize (LU5) of the self meridian and

Yingu (KI10) of the Water (kidney) meridian shouldbe tonified. Conversely, the Fire points, Yuji (LI10)

of the self meridian and Shaofu (HT8) of the Fire

(heart) meridian, should be repressed (Table 8).

The other meridians follow the same rule described

above.

In addition, the tonification-sedation between

coldness and heat method has not been generally

applied clinically, although some doctors do use

them. The method needs to be studied in the future

from the viewpoints of differential diagnosis, which

includes the deficiency-excess methods.

Cold

Lung coldnessHT8, LU10

Lung fire KI10,LU5

HT8, LU10K10, LU5

Fire

To tonify and sedatethe meridians and

its related fire points

To tonify fire pointof heart or small

intestine meridianand itself meridian

To sedate water pointof kidney or bladdermeridian and itself

meridian

To tonify and sedatethe meridian and itsrelated fire points

To tonify water pointof kidney or bladdermeridian and itself

meridian

To sedate fire pointof heart or small

intestine meridianand itself meridian

Symptoms

Principles

Example

Treatment points

Figure 3 Principles and channels of tonification and sedation for coldness and fire.

Table 8 Sa-Ahms points for cold and fire-symptoms

Symptoms

Cold FireMeridians

Tonify Sedate Tonify Sedate

Lung HT8 LU10 LU5 KI10 LU5 KI10 SP3 LU9

Large intestine SI5 ST41 LI2 BL66 LI2 BL66 SI5 ST41

Stomach ST41 SI5 ST44 BL66 ST44 BL66 ST36 BL54

Spleen SP2 HT8 SP9 KI10 SP9 KI10 SP3 KI3

Heart HT8 KI2 HT3 KI10 HT3 KI10 HT8 KI2

Small intestine SI5 BL60 SI2 BL66 SI2 BL66 SI8 ST36

Bladder SI5 BL60 SI2 BL66 SI2 BL66 ST36 BL54Kidney HT8 KI2 KI10 HT3 KI10 HT3 SP3 KI3

Pericardium HT8 PC8 PC3 HT3 PC3 HT3 SP3 PC7

Triple energizer TE6 BL60 TE2 BL66 TE2 BL66 TE6 BL60

Gall bladder GB38 SI5 GB43 BL66 GB43 BL66 BL54 GB34

Liver LR2 HT8 KI10 LR8 KI10 LR8 LR3 SP3

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Sa-Ahm Five Element acupuncture theory 317

4. Discussion

The goal here is to summarize the basic theory of

Sa-Ahms acupuncture, consisting of the Five Shu

points, as well as their clinical application, and

then to discuss them from the perspective of over-

all acupuncture treatment.

4.1. The characteristics of the Five Shupoints

The Five Shu points distal to the elbow and knee

correspond to the Five Phases and include a tonifi-

cation and a sedation point. First, the tonification

point that corresponds to the Mother Element

according to the law of the Five Phases tonifies the

energy of the corresponding channel and organ.

The tonification points are selected in deficiency

conditions of organs and channels with stimulation

by the tonification methods. Second, the sedative

point of the Five Shu points corresponds to theSon Element according to the law of Five Phases.

The Qi of channels and organs can be sedated by

stimulation of these points, and thus the sedative

points are needled in excess conditions with stim-

ulation by the sedative method. Third, the en-

ergetic action of the points situated in the section

of channels below the elbow or knee joints is much

more dynamic than other points, which explains

their frequent use in clinical practice, because at

the tips of fingers and toes the energy changes po-

larity from Yin to Yang or vice versa. Five of the

points situated along this section of channel areparticularly important and called the Five Trans-

porting points; they also coincide with what are

called the Element points, but the dynamic of

these points is irrespective of their Five Element

character.

4.2. The basic theory of Sa-Ahmsacupuncture

Gao-Wu was the first acupuncturist to describe the

use of tonification and sedation points along the

self meridian using the Five Shu points during

the Ming Dynasty (1519 AD). The basis of his treat-ment was the creation (mother-child) cycle and is

included in the Four Needle method with the

following rules: to determine the tonification point

for a meridian, select the Mother Element on the

meridian in question, and to determine the seda-

tion points, select the Child Element. But Sa-Ahm,

on the basis of Gao-Wus treatment, created a Five

Element acupuncture therapy by adding the con-

trol (grandmother-grandchild) cycle, as well as se-

lecting acupuncture points among other related

meridians. From the above approach, this theory

consisted of two tonification and two sedation

points, which are selected from among the Five

Shu points. These five points have characteristics

of their particular Five Element theory according

to the difficult issues in Nan-Ching. But its princi-

ples originate from the creation and control cycles

among the Five Elements and have the following

rules: to determine the tonification and sedation

points for a meridian in deficiencies, first, for se-

lection of tonification points, select its mother el-

ement on the meridian as well as the master point

on the mother element, and second, for selection

of sedation points, select its Controller Element on

the affected meridian as well as the master point

on the Controller Element meridian; to determine

the tonification and sedation points for a meridian

in excesses, first, for selection of sedation points,

select its Child Element point on the affected

meridian as well as the master point on the Child

meridian, and second, for selection of tonification

points, select its Controller Element on the af-fected meridian as well as the master point on the

Controller meridian.

There is another coldness-fire acupuncture treat-

ment, derived from the deficiency-excesses acu-

puncture treatment, that is simple and rarely used

because it selects only Water and Fire points among

a meridian and has the following rules: for cold

symptoms, to determine the tonification and seda-

tion points for a meridian, first, for selection of

tonification points, select its Fire Element point on

the affected meridian as well as the Fire point on

the Fire meridian, and second, for selection of se-dation points, select its Water Element on the af-

fected meridian as well as the Water point on the

Water meridian.

For heat symptoms, to determine the tonifica-

tion and sedation points for a meridian, first, for

selection of sedation points, select its Fire Element

point on the affected meridian as well as the Fire

point on the Fire meridian, and second, for selec-

tion of tonification points, select its Water Element

on the affected meridian as well as the Water point

on the Water meridian.

4.3. The merits and faults of Sa-Ahms FiveElement acupuncture

The scope of Sa-Ahms treatment can be extensive

because of its diverse laws, such as the promotion

and inhibition cycle among the Five Elements and

its connected meridians. A meridian consists of

three parts, that is, arm or foot, the more or less

of Yin and Yang, and one of six Organs and six Fus.

Seem [18] suggests that the Five Phases keep us

focused on the energetic movements of disharmo-

nies, which are fleeting and the essence of what

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318 C.B. Ahn et al

we are after, while the Eight Guiding Criteria ena-

ble us to apply a systematic analysis of all data,

gathered in a consistent manner, to measure a pa-

tients pattern of disharmony against the major

patterns of Chinese medical pathology. This can

be demonstrated in a diagram in which the Five

Phases are energetic movements with definite

cycles and the Eight Criteria are the constants

that must be assessed in whatever Phase is being

investigated.

Although there are currently many clinical books

on Sa-Ahm acupuncture in Korea, a definitive gen-

eral standard for the selection of symptom pat-

terns has not been proposed. In 1985, the general

use of Sa-Ahm acupuncture was advanced in the

following manner: the method can be used mainly

from the theoretical viewpoints ofZhang-Fus, the

etiology of disease, as well as the more or less of

three Yang and three Yin. Three examples are: in

the case of knee pain, liver tonification can be used

because the liver controls the muscle and joint ac-cording to theory ofZhang-Fus; in the case of head-

ache due to uprising of liver-Yang, liver sedation

may be used; and in the case of backache due to

dampness, either spleen-sedation to sedate damp-

ness or Yang Ming-tonification (large intestine or

stomach) to tonify dryness is employed. As these

few viewpoint examples cannot fully explain Sa-Ahm

acupuncture, study of differential diagnosis, which

many acupuncturists may have in common from

the method, is needed.

Seem [18] also noted that treatment by means

of the Four Needle technique is very powerful,should only be initiated when strong energetic ma-

nipulation is required, and only when it is certain

of the primary Element or Phase affected. The re-

ason for this should be obvious; the Four Needle

technique tonifies twice and then disperses twice,

leading to a very concentrated tonifying or dispers-

ing action on the affected Element and meridian.

If the primary Element affected is not certain, it is

far more judicious to use the more gentle tonifica-

tion and dispersal points.

Kim [19] has laboriously investigated the book

of Sa-Ahm Five Element acupuncture and his works

have served as stepping stones for its careful ex-amination. He proposed that this book was written

after 1644 AD when the Experienced Treatments

of Acupuncture and Moxibustion had been pub-

lished and was based on the I-Ching, Yin-Yang Five

Elements, and the influences of Chu Tan-Hsi and

Yu Shu, who were Chinese scholars of Chinese med-

icine. The 240 acupuncture treatments described

in the book [13] consist of 100 regular forms on the

basis of 69th difficult issue, 140 irregular forms on

the basis of the 73rd and 75th difficult issues and

various special acupuncture points, which include

the source, connecting, accumulation, alarm and

back transporting points [19].

Lee, who interpreted the basic forms of Sa-Ahm

acupuncture differently, asserted that the basic

form of Sa-Ahm acupuncture, concerning the type

of acupuncture prescriptions, cannot be fully un-

derstood although there is a main form, called the

regular form [17]. As Sa-Ahm noted Muscle, bone

and meridian change endlessly. Birth, vigor, rest,

person and evolution are never stopped, they

change endlessly with the sequence of the season,

as not an Element but an evolutionary Phase, while

the five agents do not always dominate. In the pro-

moting cycle of the Five Phases, a reinforcing method

can be used and, while in control cycle of the Five

Phases, a reducing method must be used, which

means that each Element promotes like a family

in the promoting cycle, while each Element reduces

like an enemy in the control cycle. According to

this, Wang Sheng Xiu uses a reinforcing method,

while Qiu Si uses a reducing method, but some partof Sa-Ahm acupuncture, particularly of the 75th

difficult issue, was used to reinforce the mother

point as well as to reduce the child point simulta-

neously. The former is in a state of family opposing

to enemy, while the latter is in a state of family

facing trouble. He asserts that this understanding

must be included in Sa-Ahms principle. Although it

would be logical to propose this interpretation in a

sense, it remains to be studied whether these kinds

of symptoms can be found in clinical treatments.

Generally speaking, the Sa-Ahm treatment

primarily focused on the viewpoints of deficiency-excess symptoms rather than cold-heat symptoms.

However, the relationships between the deficien-

cy-excess symptoms and the cold-heat symptoms

need to be studied in detail to form reasonable

guidelines for effect-friendly treatments. As there

are many different ways to select the Five Shu

points from the various viewpoints of Five Element

acupuncture, detailed guidelines need to be de-

signed in the future for patterns of symptoms.

4.4. From the viewpoints of overallacupuncture treatment

As most illnesses contain imbalances caused by

deficiency and excess through a network of merid-

ians as well as interruptions manifested by stag-

nation and irregularities, acupuncture treatments

need to cover these two sides in correlation with

an acupoints efficacy and sedation-tonification. It

might be more effective to use an acupuncture

method based on an acupoints efficacy to correct

interruptions together and concurrently with the Sa-

Ahm treatment based on the tonification-sedation

effect to correct imbalances. It is proposed here

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Sa-Ahm Five Element acupuncture theory 319

that an acupuncture method based on an acupoints

efficacy to correct interruptions be called a branch

treatment and an acupuncture method based on

the tonification-sedation effect to correct imbal-

ances as a root treatment in relation to an acu-

puncture treatments principle.

Seem [18] stated that the choice of a local point

orients the treatment strategy to the affected en-

ergetic functional sphere or zone (in internal ener-

getic disturbances), while the distal points serve

to determine the nature of the energetic manipu-

lation (including tonification, dispersal, warming,

cooling, and harmonizing). The combination of local

and distal points forms a pattern of treatment that

resembles the pattern of disharmony treated. Ross

[7] stated that the points between the finger tip

and elbow, or toe tip and knee, are among the

most energetically powerful points of the body and

they include not only the Five Transporting points

but also the connecting points and the accumula-

tion points. This is said to be because, betweenfingers and elbows, or between toes and knees,

the polarity of the energy is changing, from Yin to

Yang or Yang to Yin, and it is where the polarity is

changing that the greatest therapeutic effects can

be produced.

Analyzing the writings of Sa-Ahm, it is apparent

that he also tried to produce more effective treat-

ments by using other acupoints, as well as by add-

ing points, with the main points firmly based on

the regular pattern. Seem explained the limitation

of the Five Element treatment [20]. The Five Ele-

ment principles taught by some schools, for exam-ple, do not apply to the use of the secondary vessels

and Eight Extraordinary Meridians. As the latter

constitute the bulk of the energetic system of acu-

puncture, the Five Element treatment strategies

seldom apply. The two dominant styles of practice,

Traditional Chinese Medicine and Five Element

acupuncture, both emphasize the Zang-Fu (called

Officials by Five Element practitioners of the

Worsley school) and the regular meridians only,

and ignore the complex surface and primal ener-

getic networks, which constitute human energet-

ics. In this sense, they are disembodied approaches

to acupuncture.Sa-Ahm tried to use other effective points to

produce more effective treatments. Beyens [21]

states that the law of Five Elements, condemned

as an uncompromising model of dynamic relations

within the body, is restored when it is considered

as a method of systemic and organized expression

of organic and clinical reality. Besides, in the field

of acupuncture, it is difficult to accept the Five

Shu points and their therapeutic use according to

the law as a reflection of any kind of reality. The

Five Elements in Chinese medicine, even more than

the Five Shu points of acupuncture, are not part of

the basic nucleus. It was necessary, however, to

examine this concept in its proper and correct per-

spective and it is known that some medical acu-

puncturists assert that the Five Elements and the

Five Shu points need to be examined in their proper

and correct perspective.

In conclusion, there are two general viewpoints

of how acupuncture works the classical Qi and

the modern biological models. Each acupoint has

a local effect on the surrounding area, the cor-

responding channel, and its related channel axis.

However, some special points, such as the connect-

ing, cleft, alarm, and back Shu points have special

effects, while the distal points, particularly the Five

Shu points located below elbow and knee joints,

correspond to the Five Phases and are used as toni-

fication and sedation points. From the viewpoint

of a biological model, the Five Shu points below

the elbows and knees not only occupy larger areas

in the cortical representation in the post-centralsensory gyrus in the brain and, from the viewpoints

of classical model, also have an energy flow with

strong dynamism due to their changes in polarity.

Sa-Ahms acupuncture treatment lies in the selec-

tion of the Five Shu points according to tonifica-

tion and sedation, which are based on the creation

and control cycles of the Five Element theory as

well as Nan-Chings issues. Sa-Ahms treatment con-

sists of deficiency and excess treatments as well

as coldness and heat treatments using the Five Shu

points. In case of deficiency, its principle lies in

tonification of the Mother points of the self merid-ian and Mother meridian as well as in sedation of

Control points of the self meridian and Control me-

ridian. In case of excess, its principle lies in tonifi-

cation of the Control points of the self meridian

and Control meridian as well as in sedation of the

Child points of the self meridian and Child merid-

ian. In case of coldness, its principle lies in tonifi-

cation of the Fire points of the self meridian and

Fire meridian as well as in sedation of the Water

points of the self meridian and Water meridian.

And in case of heat, its principle lies in tonification

of the Water points of the self meridian and Fire

meridian as well as in sedation of the Fire points ofthe self meridian and Fire meridian. Clinical appli-

cations are mostly focused on deficiency and ex-

cess treatments, and coldness and heat treatments

rarely used. Sa-Ahms acupuncture consists of the

regular form on the basis of the 69th difficult issue

as well as irregular forms on the basis of the 73rd

and 75th issues and various special points, includ-

ing the source, connecting, accumulation, alarm,

and back Shu transporting points. As there are many

different ways to select Five Shu points from the

various viewpoints of Five Element acupuncture,

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320 C.B. Ahn et al

detailed guidelines need to be designated in the

future for patterns of symptoms. Sa-Ahms acu-

puncture needs to include other kinds of acupunc-

ture methods because it emphasizes the Zang-Fu

and the regular meridians only and ignores the com-

plex surface and primal energetic networks, such

as the secondary vessels and Eight Extraordinary

Meridians which, taken as a whole with the regular

meridians, constitute human energetics. The Sa-Ahm

treatment is designed to correct imbalances of de-

ficiency or excess using the Five Shu points, while

other treatments to correct interruptions of stag-

nation or irregularities use local and special points

from the viewpoints of overall acupuncture treat-

ment. The Sa-Ahm treatment based on the Five

Elements and the Five Shu points needs to be ex-

amined in its proper and correct perspective.

Acknowledgment

This study was supported by a grant from Dongeui

University (2008AA113).

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